vault backup: 2026-04-05 15:37:59

documents/medical/santa_monica_womens_health/jiang_iui_01_2026_claim_denial.md

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+---
+type: insurance
+category: explanation_of_benefits
+person: Xiuwei Jiang
+date: 2026-03-18
+provider: Matsunga Frumovitz
+source: jiang_iui_01_2026_claim_denial.jpeg
+---
+
+# Explanation of Benefits
+
+**Retain this for tax purposes**
+**THIS IS NOT A BILL**
+
+## Meritain Health
+
+1405 Xenium Lane North Suite 140
+Minneapolis, MN 55441
+
+---
+
+**Mailed To:**
+MATSUNGA FRUMOVITZ
+2001 SANTA MONICA BLVD 970W
+SANTA MONICA CA 904042199
+
+---
+
+| Field | Value |
+|---|---|
+| Tax ID | 932637268 |
+| EPC Draft # | 0 |
+| Payment Week | 11 |
+| Payment Date | 03/18/2026 |
+| Administered By | Meritain Health |
+
+> **Please Note:** ADDITIONAL INFORMATION MAY PRINT ON BACK
+
+Your name, **MATSUNGA FRUMOVITZ**, and Tax ID have been verified by the IRS.
+
+---
+
+## Claim Details
+
+| Field | Value |
+|---|---|
+| Tax ID | 932637268 |
+| EPC Draft # | 0 |
+| Payment Week | 11 |
+| Payment Date | 03/18/2026 |
+| Page | 1 of 1 |
+
+**Patient:** XIUWEI JIANG
+**Patient Acct #:** DG100030
+**Rendering Provider:** CAROLYNE PARKS
+**Administered By:** Meritain Health
+
+| Field | Value |
+|---|---|
+| Member # | 3928092626-2 |
+| Group Name/Check# | 16404 |
+| Network | Aetna Choice POS II |
+| Claim # | KWEE52 |
+| Customer Service | 1-866-761-3018 |
+| Billing NPl | 1447348930 |
+
+### Service Line Items
+
+| Service Date | Code or Description | Explanation Code(s) | Total Charge | Allowed Amount/QPA | Provider Discount | Other Plan Payment | Other Adjustment | Co-Ins | Co-Pay | Deductible | Non-Cov | Net Payment Amount |
+|---|---|---|---|---|---|---|---|---|---|---|---|---|
+| 01/17/26 | 89552 | 760 | 600.00 | 0.00 | 0.00 | 0.00 | 600.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
+| | | | | | | | | | | | | |
+| *See NOTE-0001* | | **Claim Total:** | 600.00 | 0.00 | 0.00 | 0.00 | 600.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
+
+---
+
+## Statement Summary
+
+| Administered By | Total Charge | Allowed Amount/QPA | Provider Discount | Other Plan Payment | Other Adjustment | Co-Ins | Co-Pay | Deductible | Non-Cov | Net Payment Amount |
+|---|---|---|---|---|---|---|---|---|---|---|
+| Meritain Health | 600.00 | 0.00 | 0.00 | 0.00 | 600.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
+
+---
+
+## Explanations
+
+| Administered By | Codes | Description |
+|---|---|---|
+| Meritain Health | 760 | These services are not covered by your health plan but are handled through Progyny. For all related services, please contact Progyny or call 844-724-8366 for more information. |
+
+**NOTE-0001:** Provider discount through Aetna Choice POS II. Patient not responsible for this amount.
+
+We are accepting claims electronically through CastIQ, Claimnet, or WebMD. Our Payer ID is 41124.
+
+---
+
+**IMPORTANT NOTICE REGARDING TRANSMISSIONS OF PROTECTED HEALTH INFORMATION:** Protected Health Information (PHI) is individually identifiable health information within the meaning of the Health Insurance Portability & Accountability Act of 1996 and the regulations promulgated thereunder. Any PHI contained in this fax is intended only for the intended recipient and is disseminated subject to the understanding that all requirements of HIPAA and other applicable laws for this disclosure have been met. If this communication contains PHI, you are receiving this information subject to the obligation to maintain it in a secure and confidential manner. Re-disclosure without additional consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties as described in state/federal law. If you are not the intended recipient, you are hereby notified that any disclosure, copying or distribution of this information is strictly prohibited. If you have received this message in error, please notify the sender.
+
+Payment technology licensed under U.S. Patent RE43904 and U.S. Patent RE44478.

documents/medical/santa_monica_womens_health/jiang_iui_01_2026_payment.md

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+---
+type: payment
+category: payment_history
+person: Xiuwei Jiang
+date: 2026-03-27
+provider: Santa Monica Women's Health, Inc.
+source: jiang_iui_01_2026_payment.jpeg
+---
+
+# Open Item Payment History By Account
+
+**Santa Monica Women's Health, Inc.**
+
+03/27/2026 10:14 AM — Page 1
+
+## Selections
+
+| Field | Value |
+|---|---|
+| Thru Post Date | |
+| Accounts | 40068 |
+| Options | Include Satisfied Items Since 01/17/2026, Include Check Amount in Check Description |
+
+## Account: 40068 — Jiang, Xuewel
+
+**Phone:** (254) 214-9350
+
+| Serv Date | Patient | Post Date | Units | Proc | Diag | Prov | Encounter | St | Ins 1 - Date Billed | Ins 2 - Date Billed | Amount | Summary |
+|---|---|---|---|---|---|---|---|---|---|---|---|---|
+| 01/17/2026 | Jiang, Xuewel | | 1.00 | 58322 | N97.9 | CP | | GT | PVPP2M - 01/30/2026 | | 600.00 | |
+| | | 01/17/2026 | Posted to PVPP2M | | | | | | | | | |
+| | | 03/19/2026 | Transfer to Guarantor | | | | | | | | | |
+| | | 03/19/2026 | Payment from Guarantor for $600.00 posted 01/17/2026 | | | | | | | | -600.00 | |
+
+### Summary
+
+| | |
+|---|---|
+| Charge Balance | 0.00 |
+| Total UC | 0.00 |
+| **Account Balance** | **0.00** |
+| **Report Balance** | **0.00** |

documents/medical/santa_monica_womens_health/jiang_iui_01_2026_receipt.md

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+---
+type: receipt
+category: account_receipt
+person: Xiuwei Jiang
+date: 2026-01-17
+provider: Santa Monica Women's Health, Inc.
+source: jiang_iui_01_2026_receipt.jpeg
+---
+
+# Account Receipt
+
+**Santa Monica Women's Health, Inc.**
+2001 Santa Monica Blvd 970W
+Santa Monica, CA 90404-2199
+(310) 829-7878
+
+Page 1
+
+---
+
+**To:**
+Xuewel Jiang
+12421 Sanford St
+Los Angeles, CA 90066-6954
+
+| Field | Value |
+|---|---|
+| Receipt Date | 01/17/26 |
+| Account Number | 40068 |
+
+---
+
+## Transactions
+
+| Date | Description of Transaction | Amount | Ins Resp |
+|---|---|---|---|
+| | **Jiang, Xuewel** | | |
+| 01/17/2026 | ARTIFICIAL INSEMINATION | 600.00 | * |
+| | **Payments** | | |
+| 01/17/2026 | Precollected payment | -600.00 | |
+
+---
+
+## Account Summary
+
+| | |
+|---|---|
+| Previous Balance | 0.00 |
+| Current Activity | 0.00 |
+| Ending Balance | 0.00 |
+| Total Guarantor Due | 0.00 |
+
+| | |
+|---|---|
+| Current Activity | 0.00 |
+| Due From Guarantor For 01/17/26 | 0.00 |